Psychology Articles

I’m always impressed by the power of our ‘unconscious.’ I realize that people have a range of models for conceptualizing how our minds work; my own combination of education, analysis, and observation has led to an understanding that ‘works for me.’

My conscious mind works in series, holding one or two thoughts at a time and proceeding in a somewhat-linear fashion. The unconscious, on the other hand, is an amalgam of countless processes that never end, epiphenomena of the constant barrage of sensations, emotions, and memories that are sorted, compared, associated, and recorded.

At least that’s how I see it.

The unconscious is not something that can be figured out, no matter how much insight a person may develop. During treatment for addiction I thought that if I could discover my unconscious motivations for using, my desire to use would cease. I don’t see it that way now. Even after more than a decade of sobriety, I am aware that my unconscious mind remains intertwined with the addictive parts of my personality, forever inseparable.

My unconscious mind protects me from unpleasant emotions. Some insights are deemed, by whatever determines my conscious experience, as too painful. But even when I’m not allowed to have a certain awareness, I can sometimes infer what is going on beneath the surface using the clues evident in my behavior.

For example, I’ve been struggling to write for several weeks now, since my dad’s death. I don’t know for certain what unconscious thought or emotion is getting in the way, but I’m aware that something has changed. The ideas that arise as potential topics seem unworthy of my attention and uninteresting to readers. I sit down to type, but the words don’t come.

I can guess what might be going on…. maybe on some level I’m angry that he isn’t reading my posts anymore. Maybe I wrote out of efforts to impress him, and now I have nobody to impress. Maybe I’m just hurt or sad at the loss, and the small child in me is refusing to cooperate. It could be any or all of those things, or …

My dad passed away two days ago, one day after his 89th birthday. It doesn’t feel quite right to post something so personal. But it feels more wrong to write about anything else.

Writing was a source of tension between us in some ways. My perspectives on myself, my parents, and my upbringing have changed over the years, and I tried to share my observations with my dad in several short essays centered around memories from my childhood. The efforts were a mistake. I learned that insight develops in each of us at different rates and in different directions, and my ‘aha’ moments—realizations about how my dad shaped my development— felt to him like criticism. I don’t think he fully realized that I accepted him, loved him, and respected him.

As for my ‘aha moments’, I don’t assume that my realizations and insights are accurate. As my perceptions change over the years, I try to remain open to two alternate explanations for those changes—that with age I’ve learned, through wisdom, to see things more accurately, or that with age my thought process is becoming more rigid and any newfound ‘insight’ is an illusion, a product of that rigidity.

My dad was an intellectual, who read more books about philosophy and theology each year of his adult life than I’ve read in my lifetime. So when our understandings of the world differed, I had to at least consider that my own judgment was off, rather than assume that old age impacted HIS judgment.

So to sort things through, I wrote. I honestly thought that with enough effort, we would fully understand how we each see things; not that we would necessarily agree, but that we would fully understand each other’s perspective. But I eventually decided that at least for us, differences in our individual perspectives ran too deep for us to completely understand each other— no matter how hard we tried.

My dad grew up during the depression, fought in Germany during WWII, became an attorney on the GI Bill, and worked for the Atomic Energy Commission before settling down in private practice …

I generally write positive articles about the use of buprenorphine for treating opioid dependence, and my articles have been reflective of my attitude toward the medication. The field of psychiatry encompasses more conditions than it does effective treatments for those conditions, and my initial experiences treating people with buprenorphine were strikingly positive.

My first buprenorphine patients were extremely desperate after multiple treatment failures, and they responded to buprenorphine the way a person with strep throat responds to penicillin. Their lives improved so dramatically that I wondered if we needed a new understanding of ‘character defects’; whether the shortcomings should be seen not as semi-permanent flaws, but rather as dynamic, maladaptive personality traits, fueled and sustained by active obsession for opioids— and lessened when that obsession was reduced, using buprenorphine.

I still have a number of those patients in my practice, people who have done very well on buprenorphine and have little interest in discontinuing the medication. As much as I would like to take on a few new patients, I won’t force these people off buprenorphine in order to make room under the cap. They have worked hard, done well, and have earned the right to a medication that helps keep their illness in remission.

But I’ve noticed a change over the past couple years in the attitudes of patients coming for treatment. I’ve been slow to specifically identify the change, but when I do an honest assessment, a clear pattern emerges. To be blunt, young people don’t do as well on Suboxone or buprenorphine as their older counterparts. Maybe they have a harder time accepting the limits to their own mortality; maybe insight requires a longer time to accumulate life experiences. Maybe they haven’t suffered enough consequences. But after starting buprenorphine, instead of tearfully expressing disbelief over the lifting of cravings for opioids, younger patients are more likely to take the effects from buprenorphine in stride and continue to engage in addictive behaviors.

I always consider each new patient’s history of ‘consequences’. I believe that consequences are what eventually spur recovery, providing the patient lives long enough for that to happen—which is certainly not a given with …

A late post tonight, since my new exercise program has pushed my blogging back by an hour or so each night. My suspicions about exercise were correct, by the way; it is much easier to suggest exercise to other people than it is to actually exercise. I’ve been at it since the beginning of the year, and I at least feel a bit less hypocritical.

While I’m on the topic… I’ve received many comments over the years from people complaining that they’ve been taking Suboxone or buprenorphine for X many years, and they have no energy, they feel stressed, they have gained weight, they don’t sleep well or they sleep TOO well… and concluding that all of the problems are from Suboxone.

They aren’t.

The problems are the result of other things, including things that tend to occur naturally as our lives become less chaotic and more outwardly-secure. The problems I mentioned above, for example, come from inactivity. They come from thinking that we’ve ‘paid our dues’ at the age of 30, and it’s time to coast in life. They come from failing to seek out challenges, and from failing to do our best to tackle those challenges. They come from letting out minds be idle, smoking pot or watching American Idol instead of responding to the naggings sense of boredom that ideally pushes people to join basketball, tennis, or bowling leagues.

Our minds and bodies are capable of SO much. I (honestly) am not a network TV viewer, but I love the contrast of ‘before and after’ scenes on ‘Biggest Loser.’ People magazine (it sits in my waiting room) had a section a while back about people who lost half their body size, by exercise and dieting. The part I found most interesting was the deeply personal answer that each person had to the question, ‘what was your turning point?’ Each cited an episode of humiliation or shame that lifted the veil of denial, and helped them do what they knew, all along, needed to be done.

We are not all capable of ‘Biggest Loser’ comebacks. But it is important for people to understand that feeling good, physically or …

Message from a reader:

I am trying to determine what my best course of action might be in dealing with protracted withdrawals from a number of drugs, including benzodiazepines.

My history is as follows: I was snorting Oxycontin for about 6 months and went into treatment to stop. Before entering the rehab hospital they put me on Clonidine .2 mgs, Ambien 12.5 mg and Sertraline 50mgs for about 1-2 weeks. Once hospitalized they switched me to Mirtazapine 15 mg, Clonazepam 1 mg and Cymbalta 20 mg., and I was on these for 5-6 months.

I took myself off all three of the last meds over a week or two, becoming free from all drugs. I believe stopping these medications cold turkey affected my CNS. I don’t drink alcohol or smoke pot. I basically stopped interacting with all of my friends to stay away from all drugs and alcohol.

I still feel awful. My primary symptoms are anxiety, depression, foggy-headed and depersonalization.

I have read posts from a woman who goes by username “Polenta,” from a site called benzo buddies, who is nearly 80 and has been in withdrawal for 20 years.

Will I fully heal? Does everybody heal no matter how far out they are? This Polenta woman says she knows of people who are as far out as her, or farther. My big question that plagues me is whether these people recover mentally? I’m aware there are physical and mental symptoms; I only suffer from mental symptoms. Polenta said in another post that Una had said there were people out even farther out who recovered, even a person 25 yrs. out. I’m wondering if that person was like Polenta and suffered from mental issues and still recovered to have quality of life.

Would I benefit from starting a low dose of an antidepressant and then tapering very slowly off to help stabilize my CNS? I greatly appreciate any advice that you can offer me. I’ve been in a lot of pain these last couple years and believe that someone with your professional and personal experiences can help me find some answers.

Tom

My Thoughts:

Hi Tom,

I hear similar complaints frequently. Just today I saw …

A question was asked about the last post that warrants top billing:

“Buprenorphine acts similar to opioid agonists in lower doses, with the same addictive potential as oxycodone or heroin. In higher doses—doses above 8 mg or 8000 micrograms per day—the ‘ceiling effect’ eliminates interest and cravings for the drug.”

I’m not sure I followed this. Can you explain more? What would you think about someone who is taking 1-2mg of Suboxone twice a day without a prescription, and says they want to stay on that dose once they find a prescriber? Are they better off on 8mg or more per day, or would it be ok for a prescriber to keep them at the lower dose? Is the answer the same if they hope to taper off the medication completely within a year (they don’t feel able to do this on their own right now, but hope to be able to when some life circumstances change). Thanks!

This gets a bit complicated, but I’ll do my best. A couple background issues; buprenorphine has a ‘ceiling’ to its effect, meaning that beyond a certain dose, increases in dose do not cause greater opioid effect. That is the mechanism for how buprenorphine blocks cravings.

As a solo-practice psychiatrist, I am more connected to the cost/value equation of my services than the typical system-employed physician. I’ve also written in prior posts about my concerns with modern psychiatry. I have worked in a variety of settings over the course of my career, and I realize that coming to an understanding of something as complicated as another person’s subjective life experience is a very difficult endeavor.

At the very least, such an understanding takes time. It also takes a willingness to maintain the constant recognition that my perception may be wrong, and may be the result of my own bias. Finally, it takes a certain amount of intelligence. Over time, certain patterns of thought become apparent and easier to recognize– but these patterns are extremely complex, and trying to provide insight into such patterns, without causing a person to take offense, requires intelligence, patience, and tact.

I have come to the realization (a somewhat surprising realization, frankly) that psychiatry works, when practiced properly. I’ve come to realize that the ten-minute med check is worse than worthless, as a ten-minute glimpse of a person’s day is more likely to lead to the prescribing of a harmful medication than a helpful one.

I think that it is because of my own experiences as a study participant back in medical school that I get such a kick out of volunteer studies today. Years ago, my classmates and I were paid to undergo bronchial lavage (a procedure where a tube is passed into the lung and the alveoli rinsed with fluid—all while wide awake), to be infected with the cold virus and then receive various treatments (administered by squirting substances up the nose), and to take antidepressants or other medications to allow researchers to screen for side effects. The greater the inconvenience, risk of injury, or physical discomfort, the bigger the payoff for test subjects.

We were often faced with the question, ‘how bad do I need the money, and how much pain can I tolerate to get it?’ Oh, the things med students will do for $100!

A new study out of Great Britain reminds me of those desperate days as a research subject, and also bears relevance to prior discussions here. The study, published in the Journal of Science Translational Medicine, subjected volunteers to a beam of heat applied to the leg, to induce pain that was 70% of what the volunteers thought they could tolerate. The subjects were then given an intravenous infusion of a potent, ultra-short-acting narcotic called remifentanil, all while having their brains imaged by fMRI, an imaging technique that determines electrical activity in certain brain areas by measuring regional blood flow.

Researchers in Pisa, Italy recently published findings from a study of heroin addicts treated with either buprenorphine or methadone. The study was a follow-up to earlier studies by the same group; one that examined the personality characteristics of heroin addicts, and a second that measured the impact of agonist treatment on psychiatric symptomatology and the quality of life of heroin addicts.

The recent third study, published in the Annals of General Psychiatry, divided heroin addicts according to personality traits, and then examined whether these personality traits predicted success with one agonist treatment over another (i.e. methadone vs. buprenorphine).

‘Agonist treatment’ is used in the Italian studies to refer to maintenance with methadone or with buprenorphine—even though buprenorphine is technically a ‘partial agonist’ rather than an ‘agonist.’ Personality characteristics were defined using an instrument called the SCL-90 (Symptom CheckList-90).

In the first study, researchers found that the 1000 or so addicts could be divided into five subgroups, according to clusters of symptoms. One subgroup was characterized by depressive symptoms. The second was characterized by somatic symptoms, i.e. focus on physical symptoms and complaints. The third group was characterized by ‘interpersonal sensitivity’ and symptoms of psychosis—such as delusions. The fourth group had significant panic or anxiety symptoms, and the final group had symptoms related to violence toward self or others, including suicidality and self-mutilation.

I relapsed in 2000 after seven years of sobriety, and my attachment to opioids progressed much more rapidly than during my initial addiction. I wrote a post a number of months ago that described ‘living on two levels,’ and that was my experience at the time—as if one part of my personality was frantically taking ever-increasing doses of dangerous narcotics while the other part, horrified, looked on.

Eventually my behavior caught the attention of enough people that I was confronted about my addiction. I had been trying to stop using on my own for several months, but I argued over the need for residential treatment. I remember sitting with the hospital CEO, babbling that I would be able to straighten myself up on my own if I had a few weeks of sick-time, and his response: ‘Jeff, you have needle marks on your hands!’